Clinical Voices March 2021

Mar 01, 2021

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Lower Ketamine Dose May Be as Effective

Adverse effects were significantly higher in the high-dose group after 15 minutes but similar after 30 minutes.

A study on acute pain relief for patients in emergency departments (EDs) shows that a lower dose of intravenous sub-dissociative ketamine is non-inferior to a higher dose that tends to have adverse effects.

According to "A Randomized, Non‐Inferiority, Controlled Trial of Two Doses of Intravenous Sub‐Dissociative Ketamine for Analgesia in the Emergency Department," in Academic Emergency Medicine, a 0.15 mg/kg dose produced a similar mean pain score as a 0.3 mg/kg dose in a double-blind trial. "Our data did not detect a large difference in analgesia or adverse effect profile between 0.15 mg/kg IV ketamine and 0.3 mg/kg in the short‐term treatment of acute pain in the ED," the study notes.

The non-inferior study included 98 patients, divided evenly into the two groups, with a primary outcome of a pain measurement on the 11-point numerical rating scale (NRS) after 30 minutes. The mean NRS in the low-dose group was 4.7, and the mean NRS in the high-dose group was 5.0.

Adverse effects commonly associated with ketamine can include hearing changes, dizziness and disorientation. The adverse effects were significantly higher in the high-dose group after 15 minutes, but after 30 minutes the effects were similar.

Crystalloid Therapy for Fast DKA Resolution

Balanced crystalloid therapy may be the preferred isotonic fluid solution.

Compared with saline, fluid therapy with a balanced crystalloid solution resolves diabetic ketoacidosis (DKA) significantly faster for adults treated in the emergency department.

"Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis: A Subgroup Analysis of Cluster Randomized Clinical Trials," in JAMA Network Open, suggests that balanced crystalloid therapy "may be the preferred isotonic fluid solution for acute management of DKA."

The study, involving 172 patients, compared saline and crystalloid intravenous therapies in a subgroup of adults presenting with DKA in two companion trials conducted from January 2016 to March 2017 at Vanderbilt University Medical Center, Nashville, Tennessee. Crystalloid therapy included either Ringer lactate or Plasma-Lyte A.

Median time to DKA resolution for the 94 patients in the balanced crystalloids group was 13 hours compared with 16.9 hours for 78 patients assigned to saline, which the study says is a "significant difference."

"Balanced crystalloids were associated with an absolute reduction of about 4 hours and a relative reduction of approximately 20% to 30% in the time to DKA resolution and discontinuation of insulin infusion," the study adds. "There was no subgroup or outcome in which saline appeared superior to balanced crystalloids."

Limitations of the study are that it involved a single center and was a secondary analysis of prior clinical trials. In addition, the study defined the timing of DKA resolution based on American Diabetes Association (ADA) criteria at the time of hospital discharge. A portion of study participants were discharged before meeting the ADA definition of DKA resolution.

Alteplase May Benefit Patients With Unknown Stroke Onset

The meta-analysis involved more than 800 patients in four randomized clinical trials.

An analysis shows that patients with an unknown time of stroke onset may benefit from intravenous (IV) alteplase.

According to "Intravenous Alteplase for Stroke With Unknown Time of Onset Guided by Advanced Imaging: Systematic Review and Meta-Analysis of Individual Patient Data," in The Lancet, eligible patients receiving IV alteplase achieved favorable outcomes in 47% of cases, compared with 39% in placebo or standard care groups. The IV alteplase group had a higher percentage of death (6% to 3%) but a lower percentage of combined severe disability or death (21% to 25%). Intracranial hemorrhage was higher: 11 cases compared with two in the control group.

Because patients with unknown onset of stroke may be excluded from standard thrombolysis treatment, the analysis aimed to establish whether intravenous alteplase is safe and effective in such patients when salvageable tissue has been identified with imaging biomarkers.

A related article in 2 Minute Medicine notes that 20% to 25% of patients with stroke do not have a known time of onset, but the use of biomarkers to recommend IV alteplase treatment could produce "net clinical benefit."

The review in The Lancet included 843 patients from four previous trials (WAKE-UP, EXTEND, THAWS and ECASS-4), and a favorable functional outcome was defined as a score of 0-1 on the modified Rankin Scale at 90 days.

Close Racial Gap in Hypertension Trials Studying Interventions

More studies are needed to focus on hypertension in Black Americans.

Few registered hypertension trials in the United States test the efficacy of interventions specific to Black adults, a finding that indicates the need for funding agencies and trial sponsors to increase investment in this area of research.

"Trends in Hypertension Clinical Trials Focused on Interventions Specific for Black Adults: An Analysis of," in JAHA: Journal of the American Heart Association, suggests that more investment to test interventions and account for societal inequities "may help to address the additive risk of hypertension faced by Black Americans."

The analysis involved U.S.-based interventional trials for hypertension from 2009 through 2018, finding that only 52 of 956 trials on were exclusive to Black Americans.

A related article on Medical Xpress points to various difficulties in recruiting Black individuals for clinical trials. To reduce healthcare disparities, it's vital to design interventions for under-resourced communities and study their effectiveness, notes lead analysis author Alexander Zheutlin, a resident physician at University of Utah, Salt Lake City.

"We need collaboration between academics, industry and communities, who understand the barriers to achieving improved health," Zheutlin adds in the article.

Another study, published in 2018, reveals how a community-based intervention at 32 New York churches led to improved blood pressure for some Black church members with uncontrolled hypertension.

"Cluster Randomized Clinical Trial of FAITH (Faith-Based Approaches in the Treatment of Hypertension) in Blacks," in Circulation: Cardiovascular Quality and Outcomes, provided motivational interviewing and weekly sessions on healthy behaviors, including proper diet, physical activity, weight loss and stress management. After six months, systolic blood pressure for church members in the intervention group was significantly reduced compared with those in a control group who received health education only.

If this approach is widely adopted, the trial notes, "it will have significant public health impact on the reduction of the racial disparities in uncontrolled hypertension between blacks and whites."

NP-Led Remote Treatment After AMI

For low-risk patients with revascularization after MI, RIM by allied healthcare professionals was feasible and safe.

Remote management of patients' post-discharge acute myocardial infarction (AMI) care with a nurse practitioner (NP)-led team had no significantly different outcomes compared with standard in-person cardiologist-led care.

According to "Remote Postdischarge Treatment of Patients With Acute Myocardial Infarction by Allied Health Care Practitioners vs. Standard Care," in JAMA Cardiology, telemedicine follow-up appointments produced similarly low numbers of safety events, medication adjustments and left ventricle remodeling outcomes over six months. "This feasibility study demonstrates the potential for RIM [remote intensive management] to be tested on a higher-risk AMI population with reduced LVEF [left ventricular ejection fraction] or heart failure," the study notes.

The multicenter clinical trial in Singapore included 301 patients from 2015 to 2019. The "Improving Remodeling in Acute Myocardial Infarction Using Live and Asynchronous Telemedicine (IMMACULATE)" trial was conducted at three cardiac centers managed by NPs with master's degrees who averaged more than 10 years of experience.

The RIM group used a Bluetooth-enabled device to transmit blood pressure and heart rate measurements twice a day and conducted telephone consultations with NPs at regular intervals. "Among low-risk patients with revascularization after myocardial infarction, RIM by allied health care professionals was feasible and safe," the study notes.

There were no hospitalizations among the remote group for hypotension, bradycardia, hyperkalemia or acute kidney injury compared with two in the face-to-face group. Both adverse and serious adverse events occurred at nearly identical rates.

The RIM group averaged 17.8 remote consultations, compared with 2.7 average visits for the face-to-face group, but the significant difference in consultation frequency led to a 3.6-fold higher average total cost for the RIM group. "The limited window for ameliorating adverse post-MI remodeling presents itself as a unique opportunity for more cost-effective telemedicine deployment in contrast with chronic heart failure, which requires potentially perpetual deployment of telemedicine services to prevent recurrent hospitalization over a patient's health span," the study adds.

Understanding Idiopathic Pulmonary Fibrosis

These diseases present many challenges for patients, families and the healthcare team.

A free resource can provide nurses a deeper understanding of patient diagnosis and care for a range of restrictive lung diseases, including idiopathic pulmonary fibrosis (IPF).

"Idiopathic Pulmonary Fibrosis: What Nurses Need to Know," in Nursing2021, offers continuing education hours and breaks down the terminology, epidemiology, risk factors, pathology, clinical presentation, diagnosis and case management of the disease. A case study of a typical patient provides an in-depth review, including symptoms, testing, treatment and nursing considerations.

Between 20% and 50% of interstitial lung disease (ILD) cases are diagnosed as IPF, because they don't have a known cause, but ILD and IPF may be used interchangeably. Since there are close to 200 ILD subtypes and a range of abbreviations and acronyms, nurses should aim to understand the overall illness and care for patients across this broad category.

An accurate diagnosis of ILD and IPF requires a health history with details about a patient's exposure to inhaled substances in home, work and other environments. Exposure to certain metals and woods as well as vegetation dust and droppings from animals can be causes, and a family history of lung disease could indicate a genetic predisposition.

Patient care usually focuses on providing relief for dyspnea and increased work of breathing with supplemental oxygen and slowing the fibrotic process, which may involve eliminating exposures such as smoking. Functional status measured by a six-minute walk test is an important indicator of the prognosis. The disease usually progresses to death within three to five years after diagnosis, but the rate of decline can vary significantly.

Nurses should expect to provide detailed patient education on symptom management, environmental exposures and medications, including possible adverse reactions. Also, palliative and hospice care options will likely require explanations for patients and their families.

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